School of Education, Cognitive Disparities: What Role in Creating Health Disparities? Linda S. Gottfredson, PhD Presenter in Book Event, “The Health Disparities Myth: Diagnosing the Treatment Gap” American Enterprise Institute, Washington DC February 22, 2006

School of Education, Today, I Will— Agree—more plausible explanations for health disparities than treatment bias Amplify—patient-side factors include general reasoning ability (g factor) Describe—how this information can improve health & save lives

School of Education, Standard Disparities Model Race Class Income (& insurance) Less access to treatment Discriminatory treatment Education Health disparities

School of Education, Klick & Satel’s First “3 rd Variable” Race Class Income (& insurance) Less access to treatment Discriminatory treatment Education Health disparities Geographic location Variation in services Variable quality ? Cannot assume that differences = discrimination. There is a plausible alternative explanation. Patient attributes also matter

School of Education, Patients’ Central Role We are our own “primary health care providers” Lifetime self-care is key to good health—prevent disease & injury, manage daily treatment Is a complex job requiring much independent judgment People differ greatly in how effectively they use preventive & curative resources available to them Therefore, identical treatment does not produce same results Equalizing access and quality of health care does not—cannot— equalize health Introduction of national health care in Britain increased class disparities in health General rule in education too Interventions that improve the average also increase the variance

School of Education, Faulty Self-Care Race Class Income (& insurance) Less access to treatment Discriminatory treatment Education Health disparities Health literacy Patient error ? NOT just schooling Geographic location Variation in services Variable quality ? IS learning & reasoning ability General intelligence Adherence to treatment HUGE problem Vexing puzzle

School of Education, Practical Importance of Literacy % of urban hospital outpatients not knowing: Health literacy level V-lowLow OK How to take meds 4 times per day When next appointment is scheduled How many pills of a prescription to take What an informed consent form is saying Patients examine the actual vials or documents Many professionals have no idea how difficult these “simple” things are for others

School of Education, Insulin-Dependent Diabetics Urban hospital outpatients: % diabetics not knowing that: Health literacy level V-low Low OK Signal: Thirsty/tired/weak usually means blood sugar too high Action: Exercise lowers blood sugar Signal: Suddenly sweaty/shaky/hungry usually means blood sugar too low Action: Eat some form of sugar And these are their simplest tasks But how typical are these individuals?

School of Education, National Literacy Survey Items simulate everyday health tasks Analyzed what increases item difficulty (error rates) Gives scores by race, education, age, income, etc Sample item

School of Education, #1—Underline sentence saying how often to administer medication HALS LEVELS: Below Level 1 Level 1 Level 2 Level 3 Level 4 Level 5 HALS SCORES: Mean = 272 One piece of info Simple match But lots of irrelevant info % US adults routinely functioning below this level? 20% Caution! Could train them do this item, but not all like it

School of Education, ?? #2—How much syrup for 10-year- old who weighs 50 pounds? Spot & reconcile conflicting info Inference from ambiguous info Multiple features to match

School of Education, #2—How much syrup for 10-year- old who weighs 50 pounds? HALS LEVELS: Below Level 1 Level 1 Level 2 Level 3 Level 4 Level 5 HALS SCORES: Mean = % US adults routinely functioning below this level? 46% Spot & reconcile conflicting info Inference from ambiguous info Multiple features to match

School of Education, #3—Your child is 11 years old and weighs 85 pounds. How many 80 mg tablets can you give in 24-hr period? Multiple features to match Two-step task Infer proper math operation Select proper numbers to use Ignore the most obvious but incorrect number Calculate the result

School of Education, HALS LEVELS: Below Level 1 Level 1 Level 2 Level 3 Level 4 Level 5 HALS SCORES: Mean = #3—Your child is 11 years old and weighs 85 pounds. How many 80 mg tablets can you give in 24-hr period? 378 “Below minimum standard for today’s labor market” % US adults routinely functioning below this level? 99% Multiple features to match Two-step task Infer proper math operation Select proper numbers to use Ignore the most obvious but incorrect number Calculate the result

School of Education, % at Each Literacy Level, By Race NALS: College Degree White Black Hispanic NALS: High School Diploma or GED White Black * Hispanic * HALS LEVELS: Below Level 1 Level 1 Level 2 Level 3 Level 4 Level 5 HALS SCORES: Mean = HALS: Adults Aged 16+ White Black * Hispanic * General finding in all studies of cognitive skills— Blacks perform more like whites 3-4 grades below (with Hispanics not quite as far below)

School of Education, Cognitive Hurdles in Daily Self- Care: Less Obvious Examples Hypertension  No outward symptoms  So treatment is a nuisance without obvious benefits Asthma  Symptoms are obvious, but benefits of the superior drug are not Bronchodilators give immediate but only temporary relief Inhaled steroids don’t give fast relief but provide better long- term control—and reduce likelihood of emergencies Cognitive hurdles common to both  Must conceptualize unseen processes  Must assess relative risk of different actions Reasoning, not “reading”

School of Education, All scales give nearly identical results All capture same ability to “comprehend & reason—to understand, analyze, interpret, & evaluate information & apply principles & concepts” Item difficulty depends on complexity—not content—of information to be processed Same factor ProseDocQuantHealthOthers = Skill at processing complex information Any kind of content Different Literacy Scales, But Same Learning-Reasoning Ability

School of Education, Many Abilities, But One Intelligence—The g Factor All abilities correlated (not identical) g is backbone of all others Captures “a general ability to learn, reason, think abstractly” g VQSMothers General Specific ≈IQ= Skill at processing complex information Any kind of content “Literacy” (for native speakers only) =

School of Education, Apt Learning Requires Apt Reasoning and Understanding IQ MRMG Slow, simple, concrete, one-on- one instruction Very explicit, structured, hands-on Mastery learning, hands-on Written materials & experience Learns well in college format Can gather, infer information on own WhiteBlack Young Adults

School of Education, Disparities in Risk Vary by Task Complexity Level (T) IQ MRMG T4 (difficult) T1 T3T2 (easy) 85-W 98-B 50-W 85-B 15-W 50-B 2-W 15-B % Whites and Blacks at high risk of non-adherence (cognitive error)

School of Education, Distribution of Cognitive Hurdles? IQ MRMG No. of tasks ?? ? ???????? ?? ? ?? Easy is unlikelyBroad range is more likely Medical advances increase complexity ? ?? ?

School of Education, Distribution of Cognitive Hurdles? IQ MRMG No. of tasks ??????? ?? ? ?? Broad range is more likely Medical advances increase complexity ? ? ? Some complexity unnecessary, but much inherent ?? ??

School of Education, Distribution of Cognitive Hurdles? Raw mental power (scores not age-normed) No. of tasks ??????? ?? ? ?? ? ?? ? Aging lowers our ability to deal with it

School of Education, Can Minimize Cognitive Hurdles 1. Reduce task complexity, where possible 2. Provide cognitive assistance Cognitive abilities unmet need 12 Task demands

School of Education, Why g? g Theory Gives Good Guidance Strong evidence base, clockwork patterns What to do  How to audit task complexities in self-care  How to audit total job complexity (e.g., diabetes self-management)  How to audit patient populations’ cognitive needs  How to quickly estimate individual patient’s cognitive needs and supports  How to fashion instruction more sensitive to patient’s cognitive needs What to expect  Which self-care tasks will have highest error rates (non-adherence)  How changes in task complexity will change adherence rates  Size of age & race disparities to expect on different health tasks  How disparities will increase or decrease with as treatment complexity rises or falls New tools for providers—all providers More feasible than eradicating social inequality More humane than denying ability differences

School of Education, Thank you.